Health System Challenges Affecting Maternal and Neonatal Health Care Service Utilisation in the Wake of Conflict in Torit County, Republic of South Sudan: A Cross Sectional Study

Abstract

Objectives
This study examines health facility utilization for pregnancy and delivery care and the health system challenges, in the light of renewed conflict in 2016, in Torit County, South Sudan.
We collected monthly facility data retrospectively on total Antenatal Care (ANC) visits, institutional deliveries, major obstetric, and neonatal complications treated from January 2015 to December 2016. We compared 2015 data with that of 2016 when conflict re-started.
We also conducted a descriptive qualitative study based on key informant interviews and Focus Group Discussions (FGDs) to explore the health system challenges. We used a thematic approach to analyse qualitative data.
Results
ANC visits declined by 21% between 2015 and 2016. The proportion of expected births that occurred in facilities declined from 23.6% in 2015 to 16.7% in 2016 (p< 0.001) while the proportion of obstetric complications treated in facilities declined from 58.9% in 2015 to 43.9% in 2016 (p<0.001). The low national budget to fund the health system, evacuation of international health staff, flight of local health workers and disruption of drugs and medical supplies are the health system challenges identified. Economic barriers and perceived poor quality of care were the two main obstacles to access of health care services.

Full text

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Preprint:Pleasenotethatthisarticlehasnotcompletedpeerreview.
HealthSystemChallengesAffectingMaternaland
NeonatalHealthCareServiceUtilisationintheWake
ofConflictinToritCounty,RepublicofSouthSudan:A
CrossSectionalStudy
CURRENTSTATUS:POS TED
PontiusBayo
Cordaid
pontiusby@gmail.comCorrespondingAuthor
ORCiD:https://orcid.org/0000-0002-4605-080X
LoubnaBelaid
McGillUniversity
ChristinaZarowsky
UniversitedeMontreal
ElijoOmoroTahir
ToritStateHospital
EmmanuelOchola
StMary'sHospitalLacor
AlexanderDimiti
NationalMinistryofHealth,DirectorateofReproductiveHealth,SouthSudan
DonatoGreco
UniversitadegliStudidiRomaLaSapienza
DOI:
10.21203/rs.2.22678/v1
SUBJECTAREAS
HealthEconomics&OutcomesResearch HealthPolicy
KEYWORDS
SouthSudan,conflict,MaternalandNeonatalhealth,healthserviceutilization

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Abstract
Objectives
Thisstudyexamineshealthfacilityutilizationforpregnancyanddeliverycareandthehealthsystem
challenges,inthelightofrenewedconflictin2016,inToritCounty,SouthSudan.
WecollectedmonthlyfacilitydataretrospectivelyontotalAntenatalCare(ANC)visits,institutional
deliveries,majorobstetric,andneonatalcomplicationstreatedfromJanuary2015toDecember2016.
Wecompared2015datawiththatof2016whenconflictre-started.
WealsoconductedadescriptivequalitativestudybasedonkeyinformantinterviewsandFocusGroup
Discussions(FGDs)toexplorethehealthsystemchallenges.Weusedathematicapproachtoanalyse
qualitativedata.
Results
ANCvisitsdeclinedby21%between2015and2016.Theproportionofexpectedbirthsthatoccurred
infacilitiesdeclinedfrom23.6%in2015to16.7%in2016(p<0.001)whiletheproportionofobstetric
complicationstreatedinfacilitiesdeclinedfrom58.9%in2015to43.9%in2016(p<0.001).Thelow
nationalbudgettofundthehealthsystem,evacuationofinternationalhealthstaff,flightoflocal
healthworkersanddisruptionofdrugsandmedicalsuppliesarethehealthsystemchallenges
identified.Economicbarriersandperceivedpoorqualityofcarewerethetwomainobstaclesto
accessofhealthcareservices.
Introduction
AfterseveraldecadesofcivilwarandeventualsigningoftheComprehensivePeaceAgreement(CPA)
withSudanin2005(1)andattainmentofindependencein2011,SouthSudanstartedtobuildits
healthsystemsbutthiswasinterruptedbyviolentclashesinDecember,2013(2).Althoughthese
clashesstartedinthecapitalcityofJuba,violencequicklyspreadtoseveralpartsofthecountry.Torit
CountyintheformereasternEquatoriaStatewasinitiallyspared(3).However,inJuly2016,the
violenceeruptedyetagaininJubaandthistimeitspreadtoinvolveToritCounty.Thefightingdidnot
lastforlongwithinTorittownbutfrequentviolentroadambushes,inter-villageclashesandviolent
criminaloffensescommittedbyunknowngunmencontinued.Howthesefactors,coupledwith

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extremepoverty,depreciationofthecurrency,andacutefoodshortages,affectedtheaccesstoand
thequalityofmaternalhealthservicesisnotknown.Thisstudywastodocumentthehealthsystem
challengesasperceivedbykeyhealthactorsinToritCountyandhowthesechallengesimpactedon
utilizationofmaternalhealthservicesbycomparingkeyindicatorsin2015(beforetheconflict)with
2016:numberANCvisits,numberoffacilitydeliveriesandnumberofmajorobstetricandearly
neonatalcomplicationstreated.Itwillhelpgovernmentanditspartnerstoinnovateonstrategiesfor
maternalhealthservicedeliverytothepopulationduringcrisisperiods.
Methods
Studydesign
Weconductedacrosssectionalanalysisoffacility-leveldataandadescriptivequalitativestudy.
Studysetting
WeconductedthisstudyinthreePayamsofToritCountyinToritstate,RepublicofSouthSudan:
Kudo,Nyong,andHimodonge.PayamsinSouthSudanareadministrativeareasthatconstitute
countieswhichinturnconstituteastate.Theprojectedtotalpopulationforthethreepayamsin2016
was75,375(4).
Studypopulation
Thestudypopulationwascomposedofpregnantwomenandneonateswhoattendedhealthfacilities
in2015and2016inthreepayamsinToritCountyforantenatalcare,facility-baseddelivery,and
treatmentofmajorobstetric,andearlyneonatalcomplications.Thequalitativestudyinvolved
membersofcommunitiesashealthserviceusers,healthcareproviders,policymakersandstaffof
Non-GovernmentalOrganisations(NGOs).
Datacollection
Quantitativedata
WereviewedANCandadmissionregistriesonthematernitywardsfor2015and2016.Thekey
indicatorsrecordedincludednumberofvisitsforantenatalcareservices,facility-baseddeliveries,
numberofcaesareansections,majorobstetric,andneonatalcomplicationstreated.Werecorded
neonataldeathsinfacilitiesandstillbirthsfromJanuary2015toDecember2016.Themajorobstetric
complicationsincluded:haemorrhage(eitherduringantepartumperiodorpost-partum),prolonged
and/orobstructedlabour,abortioncomplications,postpartumsepsis,pre-eclampsia/eclampsia,

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ruptureduterus,andectopicpregnancy(5).
Qualitativedata
Weconductedin-depthindividualinterviews(IDI)withkeyinformantsfromtheStateMinistryof
Health(SMOH),healthcarefacilitymanagersandNGOstaff(n=19)atthestateandnationallevelto
explorehealthsystemchallenges(Table.1).Weorganized12focusgroupdiscussions(FGDs)with
variousgroupsatthecommunityleveldiscussingtheperceptionsonaccesstomaternalhealthcare
servicesincontextoftheconflict.
Table1.NumbersofinterviewsandFocusgroupdiscussions(FGDs)
Datacollectionmethods Numbers Datasources
Indepthinterviews 19 Keyinformants:policymakers;
NGOstaff,healthmanagers
FGDs 12(8to20perFGD) Communities(n=8);healthproviders
(n=3);policymakers(women’s
memberofparliament)(n=1)

Dataanalysis
Quantitativedataanalysis
Weextracteddatamanuallyfromhospitalrecords,entereditintoanExcelsheetandimportedinto
SPSSversion16forstatisticalanalysis.Weusedafrequencytabletopresentdescriptivedataforthe
twoyearsbeingcompared(2015-2016).UsingthecrudebirthrateforSouthSudanwhichwas
36.315/1000populationin2015and35.936/1000populationin2016(6),thetotalnumberof
expectedpregnancieswascalculatedforeachyear.Theproportionsofthesethatdeliveredinthe
facilitywerecalculatedforeachyear.
AccordingtotheWorldHealthOrganization(WHO),15%ofallpregnanciesexperiencemajorobstetric
complications(5).Thenumberofmajorobstetriccomplicationsexpectedineachyearandthe
proportionadmittedandtreatedinthefacilitieswascalculatedtogetthe‘metEmOCneed’.We
assumedthatbecauseofthepoorroadnetwork,lackoftransport,insecurity,andpoorreferral
systems(7),thematernalhealthservicesinToritstatehospitalwereonlyusedbythepopulationin
ToritCounty.95%CIsforproportionswerecalculatedandthedifferencesbetweentheproportions
wastestedusingchi-squaredtests.Allsignificancelevelsweresetatp≤0.05.

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Qualitativedataanalysis
Wetranslated,transcribed,andcodedwithNVivosoftwarethein-depthinterviewsandFGDs.We
usedamixedapproach(inductiveanddeductive)forthethematicanalysis(8).
Results
UtilizationofMaternalandNewbornHealthServices
Atotalof2492admissionswereretrievedin2015and2283in2016.Fig.1showsthemonthlytrends
ofkeymaternalandneonatalhealthindicatorswhichgenerallystarttoshowadeclinebetween
December2015andFebruary2016withamoredrasticdeclinefromJuly2016especiallyforthetotal
ANCvisits,totaldeliveries,andmajorobstetriccomplicationstreatedinthefacility.
Table2showsthekeymaternalhealthindicatorsasaproxymeasureforutilizationofmaternaland
neonatalhealthservices.Theproportionofallexpectedbirthsinoneyearthatoccurredinthehealth
facilitydeclinedsignificantlyfrom23.6%(95%CI=22.4-24.8)in2015to16.7%(95%CI=15.7–
17.7)in2016(p<0.001).Theproportionofallbirthsexpectedthatoccurredbycaesareansection
alsodeclinedsignificantlyfrom2.4%(95%CI=2.0-2.8)in2015to1.9%(95%CI=1.5-2.3)in2016
(p=0.047).Theproportionofallmajorobstetriccomplicationsexpectedinoneyearthatgot
treatmentfromthehealthfacilitydeclinedsignificantlyfrom58.9%(95%CI=55.4-62.4)in2015to
43.9%(95%CI=40.4-,47.4)in2016(p<0.001).TotalANCvisitsdeclinedby21%inabsolutenumbers
from4854in2015to3835in2016.
Table2.Acomparisonofkeymaternalandneonatalhealthindicators
betweenJan-Dec.2015andJan-Dec.2016
 Indicators  Numbersand
proportionsn(%) 95%CI PValue
1. PopulationprojectionsforTorit
countyfrom2008census    
  2015 140,215  
  2016 146,046  
2. Expectedbirthsfromthe
populationinoneyear    
  2015(Crudebirth
rate36.315/1000
population)
5,092  
  2016(Crudebirth
rate35.936/1000
population)
5,270  
3. Proportionofallbirths
expectedthatoccurredinthe    

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facilitiesn(%)
  2015 1201(23.6) 22.4–24.8 
  2016 878(16.7) 15.7–17.7 <0.001
4. Proportionofallbirths
expectedthatoccurredby
caesareansectionn(%)
   
  2015 122(2.4) 2.0–2.8 
  2016 100(1.9) 1.5–2.3 0.047
5. Majorobstetriccomplications
expected(15%ofallexpected
births)
   
  2015 764  
  2016 791  
6. Theproportionofmajor
obstetriccomplicationstreated
inthefacilitiesn(%)(met
EmOCneed)
   
  2015 450(58.9) 55.4–62.4 
  2016 347(43.9) 40.4–47.4 <0.001
7. Neonatalcomplications
admittedandtreatedwithin
thefacilities(n)
   
  2015 404  
  2016 436  
8. Proportionoftheadmitted
neonateswhodiedwithinthe
facilitiesn(%)
   
  2015 29(7.2) 4.7–9.7 
  2016 27(6.2) 3.9–8.5 0.278
9. TotalANCvisits(n)    
  2015 4,854  
  2016 3,835  

Perceivedimpactofconflictonthehealthsystemandaccesstohealthcare
Thefollowingsectiondescribesthechallengeswithinthehealthsystemandtheperceptionsofthe
communitiesonaccesstohealthcareservicesinthecontextofthecrisisandconflictinJuly2016.
Lownationalbudgettofundthehealthsystem
Thehealthsectorismainlyfinancedbydonorfundsasgovernmenthaslimitedcapacitytofullyfund
thesector.AHealthPooledFund(HPF)frominternationaldonorsiscurrentlyfinancingmanyactivities

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ofthehealthsystem.Thisfundisadministeredthroughimplementingpartnerswhicharemainly
internationalandlocalNGOsworkingwiththeMOHtosupportprimaryhealthcareservices,improve
thehumanresources,andstrengthenreferralsystems.
“IfthestateministryofHealthcouldbeassistedbysomepartnerstoimplementhealth
programs,thiswillhelp,becausethebudgetofthegovernmentismeagre(...).Thereisa
politicalwill,butwedonothaveenoughmoneytoimplementdesignedhealthinterventions,
partnersneedtohelpthegovernment”(FGD,Membersofparliament).
Localstaffmovedaway,andinternationalstaffwereevacuated
Themajorconcernwasthelackofskilledhealthstaff,especiallymidwivesinhealthfacilities.This
shortageisattributedinlargeparttothelongcivilwarwhichdisruptedthetrainingofhealthworkers,
“Humanresourcesarenotenough,toimplementmaternalandnewbornhealthpackage”(IDI,director
1attheSMOH).Thehumanresourceproblemhasbeencompoundedbyinadequateandirregular
salariesforsomestaff.“Thehumanresourceisinadequateandthesalaryforthegovernmentstaffis
meager”(IDI,amemberofmanagementcommittee,ToritHospital).
“Ifpartnerscanaddsomepaymenttohealthstaffinthehospitalandotherhealthfacilities,
thentheywillbemotivatedtodoalotofworkandcanattractskilfulemployeeswhoare
workingwithinternationalorganizationstocomeandworkinthehospital”(FGD,Membersof
parliament).AftertheconflictofJuly,somestaffmovedawayfromthefacilitiesdueto
insecurityandtoolittleanddelayedsalaries.MostinternationalstaffwereevacuatedfromTorit.
SCIandCORDAIDstaffleftwithinoneweekofonsetoftheconflict.
Interruptionofhealthcaresupplies
Anotherchallengeofthehealthsystemisthelackofdrugsandinadequateequipmentatthehospital
andotherhealthfacilities.“Thereisinadequatemedicalequipmentanddrugs”(IDI,coordinatorofa
humanitarianaidorganization,Torit).TheJulyconflictandtherampantroadambushesinterrupted
healthcaresuppliesreachingthefacilities.“Sincethisinsecuritystarted,ithasbeendifficulttoget
suppliesadequatelyfromJuba”(IDI,representativeanNGO)
Economicbarriersandperceivedpoorqualityofcare:obstaclestoaccesshealthcareservices

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Economicbarriersandperceivedpoorqualityofcarearethemainobstaclesidentifiedfornot
accessinghealthcare.“Wecannotaffordthesoapandsweetsneededatthematernityofthe
hospital,andthenweprefertodeliverathome”(FGD#1,women,Nyongpayam).“Thoseonnight
dutyatthehospitaljustsleepandwhenyougotothem,theyjustabuseyou.Thereisalwaysdelayin
givingdrugswhentheprescriptionisnotstamped”(FGD#1,women,Nyongpayam).
Discussion
Thisstudyhashighlightedthesignificantdeclineinmaternalandneonatalhealthserviceutilization
indicatorsinhealthfacilitiesinToritCountybetween2015and2016andtheunderlyinghealth
systemchallengesinfluencedbyrecurrentconflictinSouthSudan.
Theyear2016wasaparticularlydifficultyearforthepopulationinToritCountywithinitiallyacute
foodshortagesatthebeginningoftheyearasaresultofcropfailureduetodrought(9).This,
togetherwithdevaluationoftheSouthSudanesepoundsprofoundlyaffectedthesocio-economic
statusofthepopulationandisperceivedtohavecausedrampantarmedrobberies,roadambushes
andbanditrywhichdisplacedcertainsectionsofthepopulation(10).Whenarmedconflicteruptedin
JulyitsimplyworsenedthehumanitariansituationofthepopulationinaCountyinwhichgovernment
partnerswereill-preparedtorespondas,fortheprevioustwoyears,theirfocushadbeenontheparts
ofthecountrythathadbeenaffectedbythe2013conflict(11).Thisparalysedthehealthsystemand
affecteduseofhealthfacilities.
Severalbarrierstomaternalhealthserviceutilisationhavebeenhighlightedinstudiesfromother
partsoftheCountry.AqualitativestudyinRumbekindicatedthatsocio-culturalissuesandconflict
ledtoinsecurityleavingthehealthfacilitiesinaccessibletothepopulation(12).Thisstudyalso
indicatedthatthecommunityperceivedchildbirthasnaturalandoflowriskthatdidnotrequire
institutionaldelivery.Ananalysisofthe2010SouthSudanhouseholdsurveyattributednon-useof
ANCservicestohighilliteracyamongpregnantmothers,limitedknowledgeondangersignsfortheir
newbornsanddifficultyinaccessduetolongdistancefromtheservices(13).Althoughthequalitative
armofthecurrentstudyrevealedsimilarbarriersinaccessingmaternalandneonatalhealthservices
namely:perceivedpoorqualityofservices,lackofskilledmotivatedstaffandcostsofmedicalcare,

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thedeclineininstitutionaldeliveries,ANCvisitsandthemetEmOCneedseeninthisstudybetween
2015and2016isevidenceofhowtheconflictandinsecurityinToritCountyaddedtomultipleother
barriers.
Conclusion
ThestateMoHandpartnersshouldensureavailabilityofskilledstaff,medicinesandavoidcharging
userfeestoimprovematernalhealthserviceutilizationduringconflicts.
Limitations
Thesocio-demographiccharacteristicsofthewomenwhoaccessedthehealthserviceswerenot
identified.Thiswouldhaveshowntheinequitiesresultingfromtheconflictbasedongeographical
location,economicstatus,educationstatusorevenage.
ThefunctionalityofthefacilitiestoofferservicesespeciallyEmOCserviceswasnotassessedinthis
study,thiscouldhaveaffectedtheaccuracyofsomeoftheresultspresentedsuchasthemetEmOC
need.
Otherconfoundingfactorsthatcouldhaveaffectedthehealthsystemandledtodeclineinfacility
utilisationotherthanthefightingandsocio-economicdeclinewerenotanalysed.
Thequantitativedatapresentedhereisextractedmainlyfromfacilityrecordswhichmightnotbe
accuratelykeptinsuchaconflictsetting;however,weattemptedtocrosscheckthehealthinformation
systemreportsforconsistency.
Someinterviewswerenotrecorded,thiscouldhaveresultedintolossofinformation.
Abbreviations
ANCAntenatalCare
CRCHUMResearchcenterofHospitalCenterofUniversityofMontreal
EmOCEmergencyObstetricCare
DGDirectorGeneral
FGDFocusGroupDiscussion
HPFHealthPoolFund
MoCHeLaSSMotherChildHealthLacorSouthSudan
MoHMinistryofHealth
NGOsNon-GovernmentalOrganizations
PHCCPrimaryHealthCareCenter
PHCUPrimaryHealthCareUnit
SDGsSustainableDevelopmentGoals
SMoHStateMinistryofHealth

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UHCUniversalHealthCoverage
WHOWorldHealthOrganization
Declarations
Ethicsapprovalandconsenttoparticipate
EthicalapprovalforthisstudywasobtainedfromtheethicalcommitteeoftheMinistryofHealthof
RepublicofSouthSudan(notnumbered)amongtheotherapprovals,andawrittenconsentwas
obtainedfromallparticipantsfortheinterviewsandpermissiontoreviewhospitalrecordswas
grantedbythefacilityin-chargesaftergivingthemwritteninformationaboutthestudy.
Consentforpublication-Notapplicable
AvailabilityofDataandMaterials
Thedatasetsgeneratedand/oranalysedduringthecurrentstudyareavailableintheDryad
repository,DOI:10.5061/dryad.bj550.
Competinginterests
Theauthorsdeclarethattheyhavenocompetinginterests
Funding
ThisworkwascarriedoutwithagrantfromtheInnovatingforMaternalandChildHealthinAfrica
initiative,co-fundedbyForeignAffairs,TradeandDevelopmentCanada(DFATD),theCanadian
InstitutesofHealthResearch(CIHR)andCanada’sInternationalDevelopmentResearchCentre(IDRC).
Disclaimer:TheviewsexpressedhereindonotnecessarilyrepresentthoseofIDRCoritsBoardof
Governors
Authors'contributions
PBandLBdesignedthestudyandsuperviseddatacollection,DGdidthestatisticalanalysisofthe
quantitativedatawhileLBanalyzedthequalitativedataanddraftedthemanuscriptwithPB;CZ,AD,
EOTandEOparticipatedinintellectualcontentanalysis,methodologicalreviewandalsoreviewedthe
finalversionofthemanuscriptforconsistency.Allauthorsreadandapprovedthefinalmanuscript.
Acknowledgement
TheauthorsaregratefultoOsawaRex,ClementinaLuboya,MaryManiaandSarahKainzawhohelped

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incollectionofbothquantitativeandqualitativedata.Wealsooweadebtofgratitudetothe
participantsinthisstudyaswellastothemanagementofthehealthfacilitiesinvolvedinthisstudy,
theircooperationwasvaluable.
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Figures
Figure1
Monthlytrendsofmaternalandneonatalhealthindicatorsfrom2015to2016